<div class="infoBlock infoBlockM infoBlockA">
<div class="infoBlockHeading"><span class="t">健康保險</span>
<span class="ps">
<a href="{$CONTEXT.URL}">首頁</a> > 
<a href="{$CONTEXT.MEMBERURL}">會員中心</a> > 
<a href="{$CONTEXT.MEMBERURL}status" class="st">學生狀況</a>
</span>
</div>
<div class="infoBlockContent">

{literal}
<style type="text/css">
input.underlineText {
	border: 0px;
	border-bottom: 1px solid #000;
}
ul.mchls {
	list-style: none;
	padding: 0px;
	margin: 0px;
}
ul.mchls li {
	float: left;
	width: 80px;
}
</style>
<script type="text/javascript" language="javascript">
function mc_chk_one(obj){
	var form = obj.form;
	var as = form.getElementsByTagName("INPUT");
	for(var i=0; i<as.length; i++){
		if(as[i].type && as[i].type.toLowerCase()=="checkbox"){
			if(as[i].name && as[i].name == obj.name && as[i].value != obj.value){
				as[i].checked = false;
			}
		}
	}
}
</script>
{/literal}

<div class="infoBlockItem">
<form name="statuseditform" method="post">
<input type="hidden" name="action" value="updatestatus">
<input type="hidden" name="type" value="insure">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
  <tr>
    <td width="50%" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="5" class="editBox editBoxB editBoxC">
  <tr class="editBoxHeading">
    <td colspan="2">健康保險:</td>
  </tr>
  <tr>
    <td>保險公司 (例Prudential):</td>
    <td>{pp_inputtext name="field_hi_company" value=$CONTENT.item.hi_company class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>保險號碼:</td>
    <td>{pp_inputtext name="field_hi_number" value=$CONTENT.item.hi_number class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>團體號碼:</td>
    <td>{pp_inputtext name="field_hi_group" value=$CONTENT.item.hi_group class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>保險持有人姓名:</td>
    <td>{pp_inputtext name="field_hi_name" value=$CONTENT.item.hi_name class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>電話:</td>
    <td>{pp_inputtext name="field_hi_telephone" value=$CONTENT.item.hi_telephone class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>授權電話:</td>
    <td>{pp_inputtext name="field_hi_authphone" value=$CONTENT.item.hi_authphone class="inputText2 underlineText"}</td>
  </tr>
</table>
    </td>
    <td width="1%">&nbsp;</td>
    <td width="49%" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="5" class="editBox editBoxB editBoxC">
  <tr class="editBoxHeading">
    <td colspan="2">汽車保險:</td>
  </tr>
  <tr>
    <td>保險公司 (例Prudential):</td>
    <td>{pp_inputtext name="field_ci_company" value=$CONTENT.item.ci_company class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>保險號碼:</td>
    <td>{pp_inputtext name="field_ci_number" value=$CONTENT.item.ci_number class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>團體號碼:</td>
    <td>{pp_inputtext name="field_ci_group" value=$CONTENT.item.ci_group class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>保險持有人姓名:</td>
    <td>{pp_inputtext name="field_ci_name" value=$CONTENT.item.ci_name class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>電話:</td>
    <td>{pp_inputtext name="field_ci_telephone" value=$CONTENT.item.ci_telephone class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>授權電話:</td>
    <td>{pp_inputtext name="field_ci_authphone" value=$CONTENT.item.ci_authphone class="inputText2 underlineText"}</td>
  </tr>
</table>	
    </td>
  </tr>
</table>

<table width="100%" border="0" cellspacing="0" cellpadding="0">
  <tr>
    <td width="50%" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="5" class="editBox editBoxB">
  <tr class="editBoxHeading">
    <td colspan="2">服務套餐:</td>
  </tr>
  <tr>
    <td colspan="2">
<ul class="mchls">
<li>{pp_inputcheckbox name="field_package_1" value="1" checked=$CONTENT.item.package_1 output="方案A"}</li>
<li>{pp_inputcheckbox name="field_package_2" value="2" checked=$CONTENT.item.package_2 output="方案B"}</li>
<li>{pp_inputcheckbox name="field_package_3" value="3" checked=$CONTENT.item.package_3 output="VIP"}</li>
<li>{pp_inputcheckbox name="field_package_4" value="4" checked=$CONTENT.item.package_4 output="單買"}</li>
<li>{pp_inputcheckbox name="field_package_5" value="5" checked=$CONTENT.item.package_5 output="30天"}</li>
<li>{pp_inputcheckbox name="field_package_6" value="6" checked=$CONTENT.item.package_6 output="60天"}</li>
<li>{pp_inputcheckbox name="field_package_7" value="7" checked=$CONTENT.item.package_7 output="1年"}</li>
</ul>
    </td>
  </tr>
  <tr>
    <td width="30%">總額:</td>
    <td>{pp_inputtext name="field_package_total" value=$CONTENT.item.package_total class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>生效日:</td>
    <td>{pp_inputtext name="field_package_start" value=$CONTENT.item.package_start class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>截止日:</td>
    <td>{pp_inputtext name="field_package_end" value=$CONTENT.item.package_end class="inputText2 underlineText"}</td>
  </tr>
  <tr>
    <td>CERT 協議/存款:</td>
    <td>{pp_inputcheckbox name="field_agreement" value="1" checked=$CONTENT.item.agreement output="有" onclick="mc_chk_one(this);"} 
    {pp_inputcheckbox name="field_agreement" value="2" checked=$CONTENT.item.agreement output="無" onclick="mc_chk_one(this);"}</td>
  </tr>
</table>
    </td>
    <td width="1%">&nbsp;</td>
    <td width="49%" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="5" class="editBox editBoxB">
  <tr class="editBoxHeading">
    <td colspan="3">付款方式:</td>
  </tr>
  <tr>
    <td width="40%">{pp_inputcheckbox name="field_payment_1" value="1" checked=$CONTENT.item.payment_1 output="支票"}</td>
    <td width="20%">金額</td>
    <td width="40%">{pp_inputtext name="field_payment_total" value=$CONTENT.item.payment_total class="inputText1 underlineText"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_payment_2" value="2" checked=$CONTENT.item.payment_2 output="信用卡"}</td>
    <td>日期</td>
    <td>{pp_inputtext name="field_payment_time" value=$CONTENT.item.payment_time class="inputText1 underlineText"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_payment_3" value="3" checked=$CONTENT.item.payment_3 output="自動提款機/ 轉帳"}</td>
    <td>付款人</td>
    <td>{pp_inputtext name="field_payment_payer" value=$CONTENT.item.payment_payer class="inputText1 underlineText"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_payment_4" value="4" checked=$CONTENT.item.payment_4 output="其他"}</td>
    <td>收款人</td>
    <td>{pp_inputtext name="field_payment_receiver" value=$CONTENT.item.payment_receiver class="inputText1 underlineText"}</td>
  </tr>
</table>	
    </td>
  </tr>
</table>

<table width="100%" border="0" cellspacing="0" cellpadding="5" class="editBox editBoxB">
  <tr class="editBoxHeading">
    <td colspan="2">服務項目</td>
  </tr>
  <tr>
    <td width="50%">{pp_inputcheckbox name="field_items_1" value="1" checked=$CONTENT.item.items_1 output="1. 學校溝通"}</td>
    <td>{pp_inputcheckbox name="field_items_16" value="16" checked=$CONTENT.item.items_16 output="16. 全國各地的人口情況"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_2" value="2" checked=$CONTENT.item.items_2 output="2. 住宿安排"}</td>
    <td>{pp_inputcheckbox name="field_items_17" value="17" checked=$CONTENT.item.items_17 output="17. 汽車租賃"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_3" value="3" checked=$CONTENT.item.items_3 output="3. 各州的醫療資訊"}</td>
    <td>{pp_inputcheckbox name="field_items_18" value="18" checked=$CONTENT.item.items_18 output="18. 城市活動"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_4" value="4" checked=$CONTENT.item.items_4 output="4. 交通安排"}</td>
    <td>{pp_inputcheckbox name="field_items_19" value="19" checked=$CONTENT.item.items_19 output="19. 家具資訊"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_5" value="5" checked=$CONTENT.item.items_5 output="5. 顧問/律師"}</td>
    <td>{pp_inputcheckbox name="field_items_20" value="20" checked=$CONTENT.item.items_20 output="20. 餐廳資訊"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_6" value="6" checked=$CONTENT.item.items_6 output="6. 銀行事宜"}</td>
    <td>{pp_inputcheckbox name="field_items_21" value="21" checked=$CONTENT.item.items_21 output="21. 通訊服務"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_7" value="7" checked=$CONTENT.item.items_7 output="7. 協助轉校"}</td>
    <td>{pp_inputcheckbox name="field_items_22" value="22" checked=$CONTENT.item.items_22 output="22. 電子秘書"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_8" value="8" checked=$CONTENT.item.items_8 output="8. 協助購買車輛"}</td>
    <td>{pp_inputcheckbox name="field_items_23" value="23" checked=$CONTENT.item.items_23 output="23. 國際聯繫及ＥＣＥ社交網絡"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_9" value="9" checked=$CONTENT.item.items_9 output="9. 公文翻譯"}</td>
    <td>{pp_inputcheckbox name="field_items_24" value="24" checked=$CONTENT.item.items_24 output="24. 網上購物"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_10" value="10" checked=$CONTENT.item.items_10 output="10. 假期服務"}</td>
    <td>{pp_inputcheckbox name="field_items_25" value="25" checked=$CONTENT.item.items_25 output="25. 美國的整體生活"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_11" value="11" checked=$CONTENT.item.items_11 output="11. 海外保險"}</td>
    <td>{pp_inputcheckbox name="field_items_26" value="26" checked=$CONTENT.item.items_26 output="26. 在美國的台灣機構"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_12" value="12" checked=$CONTENT.item.items_12 output="12. 家長探訪"}</td>
    <td>{pp_inputcheckbox name="field_items_27" value="27" checked=$CONTENT.item.items_27 output="27. 新聞"}</td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_13" value="13" checked=$CONTENT.item.items_13 output="13. 學生狀況"}</td>
    <td></td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_14" value="14" checked=$CONTENT.item.items_14 output="14. 緊急支援"}</td>
    <td></td>
  </tr>
  <tr>
    <td>{pp_inputcheckbox name="field_items_15" value="15" checked=$CONTENT.item.items_15 output="15. 回報系統"}</td>
    <td></td>
  </tr>
</table>

<table width="100%" border="0" cellspacing="0" cellpadding="5" class="editBox editBoxB">
  <tr class="editBoxHeading">
    <td colspan="2"><input type="submit" name="submitbtn" class="sbm" value="確定"></td>
  </tr>
</table>
</form>
</div>

</div>
</div>